To ensure clients and Managed Care Organization’s covered employees are provided information on eligibility, coverage, providers, general procedure instructions, and regulations regarding MCO services;
To work with MCO provider on physician credentialing, MCO additions and removals, network and problematic issues.
Works directly with clients, program managers, and MCO covered injured workers to ensure they are provided information on eligibility, coverage, provider identification, general procedure instructions, and regulations regarding Sedgwick CMS (company) MCO’S.
Works with the company Medical Director and vendor partner(s) on physician identification and credentialing processes, MCO provider additions and removals, MCO network issues; makes recommendations for resolution.
Contacts providers to verify new workers' compensation patients are being accepted; tracks credentialing of MCO providers.
Communicates with injured workers relative to the provider pre-designation rules and procedures.
Maintains MCO matrix as to the status of client's respective MCO.
Communicates with clients relative to their MCO status.
Ensures claims management system parameters are set for MCO flags.
Responds to client and MCO covered injured workers' issues; communicates issues to upper management with solution recommendation as appropriate.

Bachelor's degree from an accredited college or university preferred.
Four (4) years of related experience or equivalent combination of education and experience required to include three (3) years of customer service and one (1) year of analytical experience.
Managed Care experience preferred.
Thorough knowledge of MCO regulations, practices and procedures.
Excellent oral and written communication, including presentation skills.
PC literate, including Microsoft Office products.
Analytical and interpretive skills.
Strong organizational skills.
Excellent interpersonal skills.
Ability to work independently.
Ability to meet or exceed Performance Competencies.

Provider Network Specialist

Key skills